U.S. patent application number 09/794741 was filed with the patent office on 2002-08-29 for insurance claim filing system and method.
Invention is credited to Wiggins, Stephen K..
Application Number | 20020120473 09/794741 |
Document ID | / |
Family ID | 26903290 |
Filed Date | 2002-08-29 |
United States Patent
Application |
20020120473 |
Kind Code |
A1 |
Wiggins, Stephen K. |
August 29, 2002 |
Insurance claim filing system and method
Abstract
A method and system for enabling a service provider to file
insurance claims via the internet directly with the payer rather
than through a clearinghouse. The system has three major
components. These three components interact with both the existing
practice management system used by the service provider and with
the online claim filing systems of participating insurance payers.
The first component is a software application that is installed on
the service provider's local computer system. This software seeks
out billing information stored on that system and creates data
files suitable for filing of properly formatted claims with the
payers' web sites. The second component is a web portal that
interacts with both the first component and the payers' web sites
to keep the former up to date with the current formatting
requirements of the various payers and to facilitate the filing of
the claims electronically via the payers' web site. The third
component enables the resident software to communicate via an
internet connection to non-internet payers The present system uses
a software 37 cookie" to convey instructions to the first component
so that it can automatically connect to the appropriate page of
each payer's web site for electronic filing the claims.
Inventors: |
Wiggins, Stephen K.;
(Columbia, SC) |
Correspondence
Address: |
MICHAEL A. MANN
NEXSEN PRUET JACOBS & POLLARD LLP
PO DRWR 2426
COLUMBIA
SC
29202-2426
US
|
Family ID: |
26903290 |
Appl. No.: |
09/794741 |
Filed: |
February 27, 2001 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
|
|
60208553 |
Jun 1, 2000 |
|
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Current U.S.
Class: |
705/4 |
Current CPC
Class: |
G06Q 20/102 20130101;
G06Q 10/10 20130101; G06Q 40/08 20130101; G16H 40/67 20180101; G06Q
10/087 20130101 |
Class at
Publication: |
705/4 |
International
Class: |
G06F 017/60 |
Claims
What is claimed is:
1. A method for filing an insurance claim via a payer's web site,
said insurance claim being based on billing data, said method
comprising the steps of: obtaining a software application that
carries formatting instructions for filing a claim online;
obtaining an address for a web site of a payer that permits online
filing of claims; retrieving billing data; logging on to said
payer's web site at said address; formatting said billing data into
a billing data file in accordance with said formatting requirements
carried by said software application; and downloading said billing
data file to said payer's web site to file said claim online.
2. The method as recited in claim 1, further comprising the step of
receiving said address for said payer's web site in the form of a
cookie so that, when said cookie is retrieved, said payer's web
site can be accessed.
3. The method as recited in claim 1, wherein said software is
downloaded from a web site.
4. The method as recited in claim 1, further comprising the step of
accessing a web site for downloading said software and for
receiving a cookie containing said address for said payer's web
site.
5. The method as recited in claim 1, wherein said address is
obtained from a third party web site.
6. A method for facilitating the filing of an insurance claim via a
payer's web site, said insurance claim being based on billing data,
said method comprising the steps of: providing a software
application that formats billing data into billing data files
adapted for filing on line; and providing a web site address for
filing said billing data files on line.
7. The method as recited in claim 6, wherein said software
application is provided by downloading said software application to
a practice management system of a service provider.
8. The method as recited in claim 6, wherein said web site address
is provided by setting a cookie in said software application.
9. The method as recited in claim 6, further providing the step of
retrieving billing data from a practice management system of a
service provider.
10. The method as recited in claim 6, further comprising the steps
of: polling web sites of payers to obtain changes in format
requirements; and upgrading said software to format billing data in
accordance with said changes in format requirements.
11. A method for enabling a practice management system of a service
provider to file an insurance claim electronically via a payer's
web site, said insurance claim being based on billing data stored
on said practice management system, said method comprising the
steps of: locating billing data stored on a practice management
system of a service provider; eliminating a portion of said billing
data that corresponds to claims for payers that do not permit
online filing of claims; downloading from a payer's web site format
instructions for formatting billing data for online filing at said
payer's web site; determining an address at said payer's webs site
for filing billing data; conveying said format instructions and
said address to a practice management system of a service provider;
accessing by said practice management system said payer's web site;
navigating by said practice management system said payer's web site
to said address where billing files can be filed; formatting said
billing files; and uploading said formatted billing files.
12. The method as recited in claim 11, wherein said conveying step
further comprises the step of setting a cookie in said practice
management system, said cookie containing said address of said
payer's web site.
13. The method as recited in claim 11, wherein said conveying step
further comprises the steps of: comparing format instructions on
said practice management system with instructions downloaded from
said payer's web site to determine if said format instructions on
said practice management software are current; and conveying said
downloaded format instructions if said format instructions on said
practice management software are not current.
14. The method as recited in claim 11, further comprising the step
of polling said payer's web site for changes in format
instructions.
15. The method as recited in claim 11, wherein said determining
step further comprises the steps of: logging onto said payer's web
site; and navigating said payer's web site to locate said address
for filing billing files.
16. A system for filing an insurance claim at a web site operated
by a payer, said web site permitting electronic filing of formatted
data files based on billing data corresponding to said insurance
claim, said system comprising: a web portal programed to obtain
format instructions and a web page location from a web site
operated by a payer for filing a formatted claim; and a computer
having access to stored billing data and programmed to log on to
said web portal to receive said format instructions and said web
page location, said computer programmed to retrieve and format said
data files based on said billing data and in accordance with said
format instructions and to file said formatted data files at said
web page location.
17. The system as recited in claim 16, wherein said web portal
further comprises means for setting a cookie containing said web
page address in said computer.
18. The system as recited in claim 16, wherein said web portal
further comprises means for uploading changes to said format
instructions to said computer when said computer accesses said
portal.
19. The system as recited in claim 16, wherein said web portal
further comprises means for polling web sites of said payers for
changes in said format requirements.
20. A system for filing an insurance claim at a web site operated
by a payer, said web site permitting electronic filing of formatted
data files based on billing data corresponding to said insurance
claim, said system comprising: means for collecting billing data;
means for obtaining format instructions and a web page location
from a web site operated by a payer; means for logging onto a web
site operated by a payer and navigating said web site to said web
page location obtained by said obtaining means; means for
formatting said billing data in accordance with said format
instructions obtained by said obtaining means to create formatted
data files; and means for uploading said formatted data files to
said web page location from said formatting means.
21. The system as recited in claim 20, wherein said obtaining means
is a web portal.
22. The system as recited in claim 20, wherein said obtaining means
sets a cookie containing said web page location in said logging
means.
23. The system as recited in claim 21, wherein said obtaining means
polls said web site operated by a payer to obtain changes in said
format instructions and conveys said changes to said formatting
means.
Description
PRIORITY CLAIM
[0001] The applicant claims the benefit of the filing date of U.S.
provisional patent application serial No. 60/208,553, filed Jun. 1,
2000.
FIELD OF THE INVENTION
[0002] The present invention relates generally to the processing of
insurance claims. In particular, the present method and system
relates to filing claims electronically.
BACKGROUND OF THE INVENTION
[0003] The medical services industry is huge--measured in trillions
of dollars of goods and services each year--but is highly
fragmented. The overwhelming majority of goods and services are
rendered by doctors' offices, clinics, pharmacies, and individual
hospitals scattered throughout the United States.
[0004] Because a large percentage of the expenditures on medical
goods and services are not anticipated, most people prefer to rely
on insurance to bear at least a part of the cost. Health insurance
has in fact come to be considered an important type of insurance to
have and employers generally find health insurance for their
employees and their employees' families to be an important benefit
of employment. Although some employers decide to fund the insurance
coverage themselves--and are referred to as "self-insured"--most
businesses contract with third parties to provide medical insurance
to their employees.
[0005] For those who are not employed or not part of a family of an
insured employee, such as those who are retired and the indigent,
government programs such as Medicare and Medicaid sometimes provide
the equivalent of private insurance. Thus, the majority of the
public is covered by private insurance or an equivalent government
program.
[0006] From the large number of people who are covered by health
insurance, through all of the many organizations who provide health
care to them, comes a river of insurance claims to be processed.
Currently, approximately nine medical insurance claims are
processed per person per year in the United States. Both the
insured and those rendering health care depend on the efficient
processing of these claims for payment for those services. In many
cases the insured individuals will assign their right to collect
payment from the insurance carrier to the service providers.
[0007] Because of their substantial and widespread dependence on
revenues from insurance companies, the service providers have taken
over the task of filing the claims on behalf of their insured
patients to make certain that the claim is properly made and timely
payment is received. Naturally, there is widespread use of
computers and software to assist in this task.
[0008] The process of obtaining reimbursements from a health
insurance company for services rendered to patients must be both
effective and administratively easy to implement because of the
number of claims that need to be made and the large proportion of
their revenue dollars that comes back to service providers from
health insurance companies. However, electronic claim filing is
complicated by the fact that each payer has its own requirements
for a proper claim.
[0009] Typically, in the past, heavy use has been made of the mail
system and facsimile machines to file paper claims. Since the early
1970's, however, proprietary software systems have been developed
by individual payers that tie into the software systems operated by
the service provider (generally referred to as "practice management
systems") to facilitate electronic filing of claims. Practice
management systems are in some cases capable of generating the
electronic equivalent of the standard Health Care Financing
Administration (HCFA) 1500 claim form and transmitting it
electronically via a modem and telephone network. However, using
systems that are capable of filing claims with only single payers
is a piecemeal approach to the overall problem of filing claims in
health care practice management where the patients are insured by a
number of payers.
[0010] A different approach in claim filing has come into
widespread use by service providers. This approach relies on
intermediate parties, known as clearinghouses, which receive
billing files from service providers, sort them by payer, edit them
to create claims in the appropriate format for each payer, and
request payment from payers on behalf of the service providers.
Some clearinghouses receive the billing files as print images from
service providers and convert them to an electronic format for
further processing and transmission to the payers. Accordingly,
Clearinghouses relieve service providers of the burden of meeting
the formatting requirements of multiple payers; however, their
service comes with an associated cost and introduces a delay in
receipt of payment.
[0011] Relatively recently, payers have enabled service providers
to connect to the payer's web site via the internet for
transmission of claims. However, this approach is not practical
when a large number of claims is involved.
[0012] Thus, there remains a need for a better way for service
providers to file claims as automatically as possible with several
payers.
SUMMARY OF THE INVENTION
[0013] Briefly recited, the present invention is a method and
system for enabling a service provider to file insurance claims via
the internet directly with the payer rather than through a
clearinghouse. The system has three major components. These three
components interact with both the practice management system used
by the service provider to keep track of patient information
including billing information and with the online claim processing
systems of participating insurance companies.
[0014] The first component is a software application that is
installed on the service provider's local computer system. This
"resident" software seeks out billing information stored by the
practice management system and creates data files suitable for the
filing of properly formatted claims with the payers via their web
sites. The second component is a web portal that interacts with
both the resident software and the payers' web sites to keep the
former up to date with the current formatting requirements of the
various payers and to facilitate the filing of the claims
electronically via the payers' web site. The present system uses a
software "cookie" to convey instructions from the payers' web site
to the resident software so that the latter can automatically
connect to the appropriate pages of each payer's web site
automatically for electronic filing the claims. The third component
enables the resident software to communicate via an internet
connection to non-internet payers.
[0015] The filing of claims directly from the service provider
rather than through a clearinghouse is an important feature of the
present invention. This feature streamlines the process of filing
claims so that payment is received sooner. This approach also
eliminates the cost and delays introduced by the
clearinghouses.
[0016] Another major feature of the present invention is the use of
a web portal to collect claim format changes from payers' web sites
and to convey those format changes to the resident software at the
location of individual service providers automatically. This
feature enables the software at each service provider to format
billing data properly whenever the claims need to be filed.
[0017] Another important feature of the present invention is the
way in which the local software is instructed where to file claims
within multiple payers at each payer's web site. The local software
is enabled by use of software "cookies". Cookies are pieces of text
that a web server stores on a user's hard disk for subsequent
retrieval. Here the cookies are set by the second component of the
system, namely, the web portal, for retrieval by the first
component, the resident software. When they are retrieved, they are
used by the resident software as a website bookmark to enable it to
go automatically and directly to the appropriate part of a payer's
web site for filing claims.
[0018] Another major feature of the present invention is the
ability to communicate with insurance companies that do not have a
web sight. The resident software initiates a secure communication
link with the web portal, which redirects the connection to an
access server, and connects to a insurance company's claims
collection system.
[0019] Other features and their advantages will become apparent to
those skilled in the art of processing insurance claims from a
careful reading of the Detailed Description of Preferred
Embodiments, accompanied by the drawings.
BRIEF DESCRIPTION OF THE DRAWINGS
[0020] In the drawings,
[0021] FIG. 1 is a schematic view of the components of the present
insurance claim filing system in relation to the practice
management system of the service provider and the payers' web
sites, according to a preferred embodiment of the present
invention; and
[0022] FIGS. 2 and 3 are two parts of a flow chart and schematic
diagram of a method and system for obtaining verification of
insurance, according to a preferred embodiment of the present
method.
DETAILED DESCRIPTION OF PREFERRED EMBODIMENTS
[0023] The present invention is a system and method that allow a
service provider to file insurance claims automatically and
directly over the internet with multiple payers in the current
format each payer requires. The invention will be described in the
context of a health care service provider and health care insurance
but it will be apparent to those skilled in processes for filing
formatted requests electronically that the present invention may be
applied in these other contexts equally as well.
[0024] The term "service provider" is used herein to designate an
entity that provides healthcare treatment to the public, such as a
doctor's office, a hospital, or a clinic. The term "payer" refers
to those organizations that are obliged by statute or contract to
pay claims made by customers of service providers for the services
they render. Payers include both private insurance companies,
self-insured companies, and government and state agencies.
[0025] The term "payer" in addition to including insurance
companies, self-insured companies and governmental insurance
programs, also includes clearinghouses that broker claims for these
direct payers.
[0026] The term "practice management system" will be used to refer
to hardware and the software installed on that hardware that the
service provider uses to keep track of patient information and
demographics, appointments, billing, clinical data, charges for
services rendered and any other relevant matters in order to
perform the functions it routinely performs. The service provider
will enter various numeric, alpha-numeric, and text information,
including coded information such as the diagnosis and treatment,
usually using standard codes such as International Classification
of Diseases (ICD) code and Current Procedure and Terminology (CPT)
code. The service provider enters information into its computers by
keystrokes, voice recognition software, scanning or downloading
from another source. This information, or at least part of it, is
used to generate billing data files for use in preparing a claim.
These files may take several forms including images of the HCFA
1500 form and data streams with claims information arranged in
fields of various lengths. Although the present invention
interfaces with the practice management system to retrieve
information, the practice management system is not part of the
present invention.
[0027] Referring now to the figures, the service provider, in order
to avail itself of the present system, must have software installed
on a computer in such a way that it can communicate with its
practice management system software. Preferably this software is
installed locally and will be generally referred to herein as
"resident software". The resident software is preferably installed
when the service provider accesses a portal web site via the
internet using its internet service provider, as will be described
in more detail below. The resident software is responsible for
gathering claims and other data from the service provider's
practice management system, creating and maintaining connections
with the portal and payers, formatting claims data in acceptable
ways to payers, transmitting the formatted claims to the payers and
transmitting claims submission information to the portal. The
resident software would also gather and aggregate data from Payers
and display that data and claims submission information from the
payers to the service provider and pull software updates from the
portal.
[0028] At the portal, following completion of certain
administrative formalities, the resident software may be downloaded
to the local computer. The portal is responsible for providing
profile information, storing payer configuration information for
download to service providers, storing claim transaction
information, and storing updates of the resident software. Profile
information generally refers to the name of the service provider,
its addresses, telephone numbers, email addresses, users,
specialties of the service provider, bank name, bank address and
routing number, credit card type and account number, employer
identification number, and so forth.
[0029] Additionally, the service provider must register with payers
that have web sites that provide for claim filing. Thus, the
present system is for use in connection with (1) service providers
that have practice management systems that generate billing files
and (2) payers that permit on-line filing of claims but neither of
these is part of the present invention. The present system does
facilitates the filing of claims by the service provider by
enabling it to format the billing files and to access the
appropriate pages of the payers' web sites where those formatted
files can be filed. The portal obtains the filing information from
the payers' web sites, which information is constantly changing,
and transfers that information to the resident software when the
service provider is ready to file a batch of claims so that the
service provider can successfully file claims directly with the
payers via the internet.
[0030] The portal also helps the service provider keep track of the
claims that have been submitted and the status of payment. The
portal transmits data to a server that acts as a primary database.
The primary database operates independently with a second, backup
server acting as a backup database in case of failure of the first.
Data in the first database is replicated to the backup database to
minimize risk of loss.
[0031] The service provider, at intervals, will direct the resident
software to file claims with the payers. The resident software will
assemble the information needed to prepare billing data for each
claim from the practice management system. These data are usually
generated and identified by payer as they are created using the
payer's unique five digit identification code. Some practice
management software programs create a print image of the HCFA 1500
form; others simply create a data file for each claim.
[0032] The first component of the present system is the service
provider's computers programmed with software that is in
communication with the practice management software that may be
installed on the same computer, or, alternatively, on a computer
networked with that computer. The software on the service
provider's computer that is part of the first component of the
present invention will sometimes be referred to herein as local or
resident software.
[0033] The resident software instructs the computer to copy the
billing data generated by the practice management software and form
a data stream. The location of the billing files is identified to
it beforehand and its location incorporated into the local software
instructions. The local software then compares the payer numbers on
the billing data to the numbers on a pre-designated list of payers
to determine if any are not present on the list. For example, some
payers may not have web sites that permit online entry of claims.
The claims to be filed with these payers would have to be filed via
a different route such as by mailing a paper claim or through a
clearinghouse. The software then instructs the computer to reject
those billing data files that are intended for payers not on the
list.
[0034] The local software will then access the second component of
the present invention, namely, a web portal hosted by a server, via
the healthcare service provider's usual internet service provider
(ISP). This step is taken for two reasons. First, the local
software may need to be upgraded in order to format the billing
data in accordance with the current requirements of the payers.
Second, the local software needs to know how to navigate to and
through the payers' web sites to the pages where claims can be
filed. The first portion of this information is downloaded to the
local software from the web portal and becomes part of the
permanent software until changed. The second part of the
information to be obtained at the web portal, namely, the addresses
of the payer's web sites at which online claim filing is to take
place, is designed to expire within a relatively short period of
time after the claims have been filed, as will be explained more
fully below.
[0035] At the web portal component, the identity of the service
provider is authenticated. Although this web site is preferably
available via the internet, it is not a public site that can be
found using the usual search engines. Alternatively, the web portal
can be part of a private internet.
[0036] At this web portal, the version of the local software
installed on the service provider's computer is compared with the
most recent version stored on the server hosting the web portal
and, if different, the most recent version is downloaded to the
service provider's computer, replacing the older version stored
there. Each payer may have changes, so there may be one software
program that formats billing data for all payers in accordance with
their individual formatting requirements or there may be a separate
software formatting program for each payer, and consequently, a
current version of that claim formatting software for each
payer.
[0037] In addition to any upgrades needed to meet format
requirements, a cookie is set in the local software that points to
an address on the internet where the payer's web site permits
electronic, online filing of claims. A cookie is a data pair set on
the computer of a party when it accesses a web site. Cookies are
customarily used to simplify the downloading of web pages the site
visitor has visited before and to track the number of times the
visitor has visited a web site and the visitor's navigation through
a site. In the present invention the cookie includes the address of
a page of the web site where claims can be filed on line and the
number of the payer to which that web site corresponds. This
information acts as a browser bookmark to direct the resident
software to and through the payer's web site to the page where
electronic copies of formatted claims can be filed.
[0038] The cookie is retrieved by the local software and applied to
direct each claim in the billing data to the page of the payer's
web site where that claim is to be filed. Upon reading the code
number of the first payer on the billing data stream, the local
software instructs the service provider's computer to log onto that
payer's web site and navigate though the site to the web page that
permits claim filing. The billing data stream is reformatted in
accordance with the version of the formatting software installed on
the local software, which then proceeds to reformat the billing
data and file the claim. The claim is then filed by downloading the
formatted data stream to the payer's web site or by simulating the
keying of data into that payer's web site.
[0039] The payer's web site authenticates that the service provider
is permitted to file claims with it and then begins to receive the
electronic claims as transmitted. In the event a claim is rejected
by the payer's web site, it will be returned to the service
provider's practice management system for correction or special
handling. Otherwise, the electronic claims that are not returned
are accepted for processing. The payer's web site prepares a claims
status report for the service provider for all claims previously
filed and transmits that report as part of that session. A claims
status report for all claims accepted for processing at the current
session will be prepared and placed in a data file for transmission
to the service provider the next time the service provider logs
onto the payer's web site.
[0040] The web portal, in order to provide the software upgrade and
cookie for the service provider, polls the web sites of the payers
at intervals to determine if these web sites have announced any
format changes. It also conducts a "dry run" for claim filing by
accessing the payer's site, logging on, and proceeding through a
sequence of pages to locate the page where claims are entered. This
page is identified in the cookie.
[0041] The service provider connects to the portal to submit
transaction information, to validate and update the client resident
software with new versions, and to authenticate the portal so that
it can retrieve provider profile and payer transmission
information. This interface takes place upon installation, upon
login, prior to submitting claims to payers, upon completion of
claims submission to payers, and upon completion of data extraction
routines.
[0042] The service provider connects directly with the payer's web
site to submit claims data and receive error/response information
as soon as it extracts claims data from the service provider's
practice management system.
[0043] If the payer utilizes a non-Internet claims collection
system (such as a bulletin board system), the service provider can
access the web portal, which will redirect the connection to an
analog "access server". This device will connect via standard
analog connection to the payer to send claims.
[0044] There are a number of objects used in the resident software
and the portal software. These objects are software objects as that
term is customarily understood in connection with object-base
programming. Each object has encapsulated data and methods. The
following is a list of the primary objects on each along with a
brief description of its function.
[0045] The first object on the resident software is the "execution"
object that launches the application. This object calls all the
supplemental objects. A number of the supplemental objects are for
graphic user interface but others allow the user to execute aspects
of the residential software. One of the supplemental objects is an
"activity manager" object. This object tracks both the resident
software activity and the portal activity. Each time the method of
this software object is called, it posts a stream of data
containing basic information (such as the activity type and method)
in the form of a database line item insertion to the portal and as
a text file each to the portal.
[0046] The resident software has a "log in manager" that verifies
the presence of a live internet connection and a certificate
verifying the service provider has registered, and then
authenticates the user with a user name and password. Once
authenticated, the software permits connection to the portal. The
live internet connection is needed to download the resident
software initially and download upgrades to that software
thereafter.
[0047] Another object is a "browser connect" object that launches a
browser window and loads a preselected web page. The browser
functions an operating system.
[0048] Next, there is a "claims extraction manager" object that
connects the resident software to the practice management system of
the service provider. The claims extraction manager moves a copy of
the billing file to the same computer where the resident software
resides, reads it, validates it and parses the file. It sorts and
formats the file by payer.
[0049] Another supplemental object on the resident software is the
"download payer profile" object which downloads a "payer profile"
object to the resident software so that the resident software can
access the payer's website and file a claim. This object is a
cookie, as described above.
[0050] There is an object for posting direct claims to and
gathering responses from a payer. This object reads the payer
profiles from the payer profile object to determine the type of
connection system employed by the payer and calls the appropriate
connection method. It then compresses the response files and pushes
them to the portal. Then the response file is called.
[0051] An exit object terminates execution of the software, breaks
connection to the portal and closes the client window. A related
object breaks the connection to the portal by sending a disconnect
message from the client and expiring the session.
[0052] The "download provider profile" object checks the version of
the provider profile, downloads the entire object and, after
checking to see if the provider profile is the most current
version, applies the most current version.
[0053] Another supplemental object, the "upload software version"
object, checks the version of the resident software and downloads
and applies the most current version when appropriate. It achieves
this result by comparing the file version on the resident software
with the portal version via an HTTP (hypertext transfer protocol)
post of the object version numbers and a return HTTP response from
the portal with those objects that have been revised. The resident
software then loads the files into the appropriate location.
[0054] Another object connects to the practice management system,
moves a copy of the statement file to the local computer, reads and
validates the file and formats when necessary.
[0055] A supplemental object posts claims to the payer and gathers
the "adjudicated" responses. It first reads the payer and provider
profiles, and then navigates to the claims submission page of the
payer's web site. Individual claims are posted and responses
accumulated by this object in a file format. The response files and
transactional information are compressed and "pushed" to the
portal. Finally, the response file viewer/printer is called by this
object to display the adjudicated responses to the customer.
[0056] Related to this object is another object, a "payer
connection management" object, that establishes a connection to the
web site of the payer, authenticates the user and navigates to the
claims submission page. A "transmission activity manager" object
tracks the process of transmitting data such as claims by writing
or recording a record in a file stored locally. This file is for
recovery by the resident software.
[0057] These foregoing objects are the main objects on the resident
software. The following objects are the main ones on the
portal.
[0058] There is a gateway servlet object on the portal that handles
all HTTP requests from users. This servlet object is essentially a
traffic director when multiple users are attempting to log onto the
portal. An "install user" object records the information entered by
a user on the portal download page when the resident software is
downloaded by a service provider.
[0059] A "user" object identifies registered users to the portal
within a given service provider's account, offers registration to
the users, verifies portal roles and returns the correct profile
templates and data for portal users. The user object is verified
for portal eligibility and then populated with the correct profile
information for the user within an account for the duration of the
session.
[0060] A "user password finder" object retrieves user-related
information such as a user name, account number, and user password,
and stores them into the session context if the user name and
account numbers match the same fields in the database. A related
object, the "user question validation" object retrieves the user
password question and password answer from the session context and
compares the answer from the user against the same password answer
in the session context. If the passwords match, the password is
reset. Otherwise password mismatch message is provided to the
user.
[0061] There is an "alert" object that reads and writes alerts to
and from the database, and an "administrative payer" object that
allows administrative personnel to perform administrative functions
through the portal, namely, add, update, and delete payer-specific
information.
[0062] An "account" object identifies registered accounts with the
portal and offers registration options for the portal. The account
object is verified for portal eligibility and then populated with
the correct profile information for the duration of the session for
that account.
[0063] There is an object that defines the process for identifying
which accounts are registered with specific payers, another object
responsible for managing the data for the account practice
management system, and one for identifying the location of the
accounts the practice management system files and modifying the
location of those files.
[0064] An "activity manager" object captures pre-defined activities
performed by a user and stores a record in the database when an
action is performed. This manager object provides a method for
tracking which action has been performed in the event an error
occurs.
[0065] A "session manager" object, which is the object called by
the "servlet gateway" object, performs user validation. In
particular, it passes the user name and password to the "user"
object that will access the database for the user validation. It
will then store the user session information in the session
context.
[0066] A "client version verification manager" object manages the
updates of the present system's resident software. It determines if
the account is operating and whether it has the most recent version
of the software, and then updates those files of that account that
require it. To determine which files on the resident software that
need to be updated, a version number is maintained on each file in
the portal database. This number is compared to the number on the
corresponding files on the service provider's resident software.
The updates are downloaded.
[0067] The "client update manager" object submits a request for a
specific version of the object to the portal. The portal responds
with the requested version of the object. A "response manager"
object retrieves and stores for the portal the various response
files that have been generated and aggregated on the resident
software.
[0068] The "portal bridge" object manages connections between the
resident software and the access server. It establishes a secure
socket layer connection to the resident software, and a
transmission control protocol/internet protocol (TCP/IP) connection
to a modem connected to an access server. The resident software can
then initiate an analog dial out to a payer bulletin board
system.
[0069] There are several other administrative type objects such as
an object that enables a user with an account to retrieve and view
a claim submission history on-line, one that allows a user to
retrieve and view a payment history on line, one to gather and
store transaction information supplied by the service provider, one
to modify contact information, one for credit card information and
one for bank information for a given account. The credit card and
bank information is required in order for the service provider to
pay for the service provided by the present system.
[0070] In use, a user from the service provider's office will start
up the local computer and access the internet through its usual
internet service provider. Once logged onto the internet, the user
will go to the public part of the portal site.
[0071] The user that enters the portal web site from the internet
will have access to limited functionality within the portal. The
profile administration and help functions will be available but the
user will not be able to process claims and electronic patient
statements from the public portion.
[0072] To access the portal, the user must have a desktop computer
connected to the internet, have navigated to the portal web site,
and have a suitable web browser installed. Once at the web portal
site and authenticated, the user will be given access to portal
resources at the portal home page.
[0073] To be authenticated, the user must be a registered user of
the portal, be connected to the internet and have the resident
software installed on the user's desk top computer. The user is
then able to launch the local application, which will request
access to the private portion of the portal. The portal will pass
the authentication message back to the resident software. The
portal and resident software will then be in communication, and the
user will have access to all portal functions corresponding to the
user's role and the functions associated with that role. For
example, if the user is not an administrator, it will not have
access to administrative functions.
[0074] At this point, the most recent version of the resident
software is downloaded from the portal to the service provider's
computer. If the user does not have any version, it can download
the software from the public portion of the portal site. This
software may also be installed on the service provider's computer
using a compact disk. If the software is being installed for the
first time and not simply being upgraded with the latest version,
the user will need to supply certain profile information:
salutation, first name, last name, e-mail address, state where
practice is located, zip code, and practice specialty. The portal
will confirm with the user the location where the software is to
reside and then begin the download. The user will then be given
instructions as to how to launch the application for installation
and what information will be collected during installation.
[0075] During installation, the user's internet connection is
checked and then various information is requested. This information
includes customer information, account and billing information,
information about the user's practice management system, billing
file information, names of payers where the user has an "electronic
relationship" (is registered with that web site as a party able to
file claims there), and user names and passwords for payer sites.
The user is given the opportunity to confirm all information and to
select certain options such as the option to have printed copies of
claims mailed to it. Next, the user is given instructions as to how
to log in and told what information will be requested upon logging
in.
[0076] This registration information is checked to see that it is
unique and not a duplicate of information previously entered. If
the information is indeed unique, the registration is complete.
[0077] The portal checks the version of resident software when that
version identifier is passed from the resident software to the
portal. The identifier is compared by the portal to the current
version and, if the resident software version is not the latest,
the latest version is downloaded.
[0078] At the same time, the payer transmission profile and
decision matrix is downloaded and the service provider's user is
notified of the download.
[0079] To process claims, the claim information is extracted from
the service provider's practice management system. The resident
software establishes a connection to the practice management
system, locates the billing file, loads it, and extracts the claims
data from it. The claims data must then be formatted, sorted and
prepared for submission to a payer. For present purposes, a "payer"
is a payer with a web-based presence that accepts filing of claims
at its web site, a payer that accepts claims when a direct
connection is made, and a clearinghouse that will print and mail
paper-based claims. In order to format, sort and prepare the claims
data, they must be parsed to determine their current format and to
allow them to be sorted by payer, then the data are sorted by payer
and formatted according to each payer's specifications. Each set of
claims (corresponding to a different payer) is placed into a
separate file, the claims counted and the file closed.
[0080] The claims are then filed with each payer, one payer at a
time. The payers confirm to the local software that each claim was
successfully filed. If any failed to transmit, that information is
provided to the resident software and displayed for the user. While
logged onto payer's web sites or connected directly with payers,
the user may retrieve responses to claims previously filed.
[0081] The user may obtain a transaction activity summary
describing the claims processed, including statistics, the number
of claims submitted per payer and data and time claim was
processed. The user will have the capability to search for a
particular transaction, as well. The transaction summary is posted
to the portal which displays it to the user in a form that is
readily grasped and may be manipulated to display the transaction
information in useful ways. This is an important feature of the
present invention because it enables the user to obtain information
about is claims processing that it currently does not have and
which can be used to manage the service provider's practice
better.
[0082] It will be apparent to those skilled in processing insurance
claims that many changes and substitutions can be made to the
foregoing preferred embodiments without departing from the spirit
and scope of the present invention, which is defined by the
appended claims.
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